Diagnosis

Although I promote the transfollicular approach first, any browlift that has natural results, low complications, and happy patients is a good procedure. The diagnosis for TFSBFL is the same as for other browlift techniques. Once it is determined that a patient wants a browlift, a decision is made as to what technique to employ. When deciding which technique to use, several factors should be considered. First, the position of the patient’s hairline: if the patient already has a naturally high hairline with a long forehead, the TFSBFL is preferable, as no patient with a high hairline wants it higher. Another scenario is a patient with a significantly rounded frontal bone or frontal bossing. This exaggerated frontal curvature makes an endoscopic technique more difficult because the surgeon is working tangential to the curved bone, making it difficult to position the tip of the scope. Also, the need for drilling into the skull and using some type of retention system is a negative for many patients. It is important to let patients know preoperatively if drill holes and or hardware will be used, to ensure accurate informed consent.

Patients with permanently tattooed eyebrows can be problematic, especially if the tattoos are not symmetric or extremely peaked. When the skin is excised and the forehead retracted, an unnatural result can occur. Any patient with permanent tattooed brows should be closely evaluated for result when the brows are manually lifted, and the problem discussed while the patient looks in a mirror. Some patients have virtually no eyebrow hair and draw them on daily. This is not a problem, as they can be drawn at any height postoperatively by the patient. This type of patient is actually the best browlift candidate, as the operation improves their periorbital aging and the brows can be drawn anywhere the patient desires.

Also germane with choosing a brow technique is the use of simultaneous laser resurfacing. The endoscopic technique is subperiosteal and can be aggressively lasered in the same manner as the rest of the face. The transfollicular subcutaneous technique is a much thinner flap and more prone to devitalization. When I laser an endoscopic forehead, I use the same settings as the face, but when I laser a transfollicular subcutaneous browlift, I reduce the power or the density of the laser in the same manner that I do with facelift flaps.

For younger surgeons, it is sometimes difficult to determine which patients are appropriate (or inappropriate) candidates for brow and forehead lift. Box 4.2 shows some of the various diagnostic indications and contraindications for brow and forehead lift.

Transfollicular Subcutaneous Brow and Forehead Lift: Surgical Technique

Patients are instructed to wash their hair for several days before surgery and the day of surgery with an antibacterial soap.

As with blepharoplasty, the TFSBFL success revolves around proper preoperative incision markings, which must be precise and accurate. After photographs are taken, the patient is marked preoperatively. The area of maximum brow elevation is decided with the patient looking in the mirror. When in doubt, it is always better to be conservative. The area of maximum brow elevation is generally at the junction of the central and lateral thirds of the eyebrow, which usually coincides with an imaginary vertical line at the lateral limbus ( Fig. 4.13 ). This is a guideline and may differ in some patients, but is generally accurate. Some older females literally have no eyebrow hairs and draw them in daily, which as stated above, is a safe situation. Care must be exercised not to over-elevate the medial brows, as this can produce an unnatural and quizzical appearance. Fig. 4.14 shows the typical markings for the TFSBFL.

The brow is marked at the junction of the medial and lateral thirds or an imaginary vertical line from the lateral limbus.

Typical markings for the TFSBFL are shown. The estimated brow peaks are shown as vertical lines and the hairline incision is shown as the horizontal line.

Additional markings commonly used include the supratrochlear nerves, which are located approximately 17 mm from the midline and the supraorbital nerves, which are approximately 27 mm from the midline ( Fig. 4.15 ). Marking the neurovascular bundles allows the surgeon to be mindful of significant anatomy. Blepharoplasty markings are also performed if planned at the same procedure.

The supratrochlear nerves are located at the orbital rim approximately 17 mm from the midline and the supraorbital nerve is located approximately 27 mm from the midline. They are shown in diagram form and in vivo from an actual TFSBFL.

The instrumentation for TFSBFL is minimal and similar to facelift surgery ( Fig. 4.16 ). Most commonly used instruments include:

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  Round scalpel handles

  
  
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  No.11 scalpel blades

  
  
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  Fine pickups

  
  
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  Comb

  
  
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  Marking pen

  
  
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  Suction

  
  
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  Retractors (lighted are preferable)

  
  
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  Radiowave or electrosurgical unit for hemostasis

  
  
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  4-0 gut, 5-0 gut, and/or 6-0 nylon sutures.

The common instrumentation used for the TFSBFL.

The TFSBFL can be performed with local or tumescent anesthesia, but is most commonly performed with intravenous (IV) sedation, as other simultaneous procedures are frequently included.

Regardless of the browlift technique utilized, I personally do a simultaneous blepharoplasty in almost every case. I feel that most patients that are in need of a browlift are also in need of some upper-lid skin reduction. Obviously, eyelid closure must remain functional, so discretion is required. If the upper lids are not addressed, the patient may be left with a perfectly elevated brow but redundant upper-lid skin that detracts from the result ( Fig. 4.17 ). Also, in the event the brow is not elevated enough or minor relapse occurs, the combination of blepharoplasty and browlift provide a combined change that will usually satisfy the patient.

This patient is shown before and after successful TFSBFL browlift but the result is compromised by existing redundant upper-eyelid skin. Performing conservative blepharoplasty prevents the problem in such patients.

When performing simultaneous blepharoplasty with browlift, a much more conservative blepharoplasty procedure is invoked. Less skin is removed and the outline of the blepharoplasty incision is different from conventional blepharoplasty. When performing conventional blepharoplasty, most surgeons use an upswept incision at the lateral portion of the eyelid. This is done to assist with lateral hooding. When performing browlift surgery, the lateral hooding is automatically corrected, so there is no need to perform the upswept lateral blepharoplasty incision. The “bleph with brow” incision is tapered on both ends ( Fig. 4.18 ). Whereas a traditional blepharoplasty may dictate a 10-mm skin excision, the blepharoplasty done with browlift requires only 3–4 mm of skin excision. When combining simultaneous blepharoplasty and browlift, novice surgeons should perform the browlift first, as the amount of eyelid skin excision is more easily determined. Experienced surgeons can perform the blepharoplasty first by taking 3–4 mm of skin at the beginning of the procedure. Additionally, elevating the brow will reposition the eyelid tissues so significant muscle or fat removal is not generally necessary and simple skin excision is usually sufficient for most cases. I have never experienced a problem lagophthalmos when combining these procedures.

The upswept lateral incision used in conventional blepharoplasty (A) and the more conservative incision outline used when combining blepharoplasty with simultaneous blepharoplasty (B).

When performing blepharoplasty before the browlift, the lid incisions are closed before scalp excision is performed. The surgeon can therefore decide how much excess forehead skin can be removed without producing significant lagophthalmos. Enough skin must remain to close the lids, and this is taken into account during excess scalp excision ( Fig. 4.19 ). Novice surgeons should avoid simultaneous blepharoplasty or perform it at the end of the case to avoid significant lagophthalmos.

Blepharoplasty can be performed before the browlift, but the amount of scalp resection will be more critical. This is the patient at the end of the case after closure of the upper-lid incisions and the brow incision. Novice surgeons should perform blepharoplasty at the end of the case or as a separate procedure. Several millimeters of lagophthalmos is acceptable and will resolve when surgical edema subsides.

Crafting the Incision

There are few surgeries totally defined by a specific incision, but this is one of them. The technicality and quality of the transfollicular incision can make or break the aesthetic success of this browlift procedure. There are two basic principles of this lift. The first critical principle is to craft a precision incision to allow hair regrowth through the surgical scar, thus camouflaging it. The second principle is to elevate the brow and forehead without raising the hairline.

The incision pattern is also very critical for a naturally appearing hairline scar. First, the incision should never be made anterior to the hairline. To avoid old terminology confusion, we will refer to incisions anterior to the hairline simply as “prefollicular” hairline incisions. They are also referred to as “trichophytic” or “pretrichial” and this incision totally avoids any hair follicles. This may sound good in theory and will definitely be easier to incise and close, but the aesthetics are frequently unacceptable and produce a straight line, often hypopigmented scar ( Fig. 4.20 ). I frequently hear surgeons advocate the prefollicular hairline incision but continually see patients in my office who were operated elsewhere and have unacceptably visible scars. Even geometric, random incisions performed anterior to the hairline can heal with a very unnatural appearance ( Fig. 4.21 ).

Incisions at or anterior to the hairline are easier to surgically manage, but often leave visible and hypopigmented scars that actually draw attention to the unnatural situation.

Browlift incisions placed anterior to the hairline are obvious and unnatural appearing, even when an attempt is made to avoid a straight line and geometrically randomize the incision.

As there are very few straight lines in human anatomy, these prefollicular scars can look unnatural. Also important is the fact that there is no such thing as a “natural hairline.” Normal hairlines are not lines at all, but very incidental and random patterns of follicles. Only a toupée or a poor hair transplant produces a true “hairline.” Making a straight line prefollicular incision on a patient’s forehead can make them look unnatural, with a visible and often hypopigmented scar ( Fig. 4.22 ).

(A,B) Normal hairlines are a random transition of follicular density and (C) only toupées have an incidental straight hairline.

The transfollicular incision is unique in design. First, the incision is designed to transect the existing hair shafts and follicles at a steep bevel. This incision is intentionally placed about 5 mm posterior to the true hairline. The optimum placement of this incision is at the region of the follicular density change from the thin, sparse anterior hairs to the denser follicles of the “actual” hairline ( Fig. 4.23 ). The incision has to be placed posteriorly enough to allow the scalpel to transect enough hair shafts and follicles to regrow through the thin scar edges.

The transfollicular incision is placed about 5 mm posterior to the hairline where the follicular density transitions to the thicker hair. This incision is random and extends laterally just past the area of intended arch peak, as shown by the dotted lines. There is never a need to extend past the temporal crest as the incision ends at the brow tail in the average patient.

The bevel of the incision is critical and must transect several rows of hair shafts and follicles at different heights. In order for this to occur, the scalpel with a No.11 blade must be held about 10–20 degrees above the horizontal plane, as shown in Fig. 4.24 . This angle and scalpel movement is similar to filleting a fish, except the blade is not totally horizontal. The reciprocal motion of filleting a fish is used when the incision is made.

The angle of the scalpel with a No.11 blade is about 15 degrees above the horizontal plane and kept at this angle for the entire incision.

This extreme bevel has numerous functions. First, it allows the angled transection of hair shafts and follicles, which encourages hair regrowth through the scar. Second, this extreme bevel produces a very thin skin incision edge. Whereas an incision made perpendicular to the skin surface will produce the thickest skin edges, the more angled the scalpel is held, the thinner the skin flap edges will be. This very thin epidermal/dermal interface contributes to the excellent aesthetics of this type of skin incision. This thin interface also makes it easier for the underlying hair follicles to grow through the thin flap. When the surgeon appreciates these characteristics and can predictably perform this incision, repeatable outcomes are accomplished with this approach.

To illustrate this transition, Fig. 4.25 shows a beveled incision on a grapefruit peel; the white region corresponds to the dermis, and the yellow region corresponds to the epidermis.

(A) The extreme bevel produces a feather edge where the dermis blends with the epidermis as shown clinically and (B) using a fruit peel as an example. The elevated flap shows the white part of the peel mimicking the dermis and fat, while the yellow edge of the peel mimics the epidermis.

Incision Geometry

Keeping with incision design, the next aspect to be addressed is incision geometry. Understanding that the incision is placed about 5 mm into the hairline, the configuration can be regular with large or small triangles or irregular with random undulating geometry. Different surgeons prefer one of these configurations over the others. Proponents of large triangular incisions say that the incision, skin excision, and reapproximation of the trimmed flap is less laborious. My experience with the larger triangular configured flaps has been that the larger regular triangles show more intentional geometry, which is obvious after healing ( Fig. 4.26 ). Other surgeons prefer very tiny triangles and this is not only more labor intensive to cut and sew, but the smaller the triangles, the more the final incision resembles a straight line ( Fig. 4.27 ).

(A) Large regularly angled triangles during incision will produce (B) an orderly scar, which is more visible than randomly incised skin.

A transfollicular incision with very small triangles. Although acceptable, very small incision patterns almost equal a straight line scar. Larger random, irregular geometric patterns are optimal.

After experimenting with all the common geometric incision patterns, experience has shown that a random, irregular, undulating incision pattern produces the best postoperative scar. As stated earlier, this incision is made by using the scalpel at about a 10–20 degree angle from horizontal in a reciprocating manner like filleting a fish. The pattern is basically irregular and reminiscent of ventricular fibrillation on an electrocardiogram ( Fig. 4.28 ). The incision pattern and the angle of the cut are both critical factors in the success of this technique.

The most aesthetic incision for the transfollicular browlift is a random, undulating pattern that is similar to a ventricular fibrillation tracing on electrocardiogram. This incision is made about 5 mm posterior the hairline in an extreme beveled angle.

If a patient has a prominent widow’s peak, it is better to cut through the lower-third of the apex instead of following the distinct “V” shape of the peak. Otherwise the angles are too conspicuous with the final scar ( Fig. 4.29 ).

When attempting to include the widow’s peak in a triangle, the resultant scar appears intentional and visible (A). For patients with a widow’s peak, a better aesthetic result will result when the widow’s peak is transected to blunt the peak (B). Patients are informed of this preoperatively and experience has shown that most patients do not mind losing a slight amount of their widow’s peak as shown in (C).

Similar to blepharoplasty, correctly marking this browlift incision is critical. Marking the incision 5 mm posterior to the hairline with a conventional “Magic Marker” type felt marker with an angled tip, provides a basis for the incision outline. The marker is used to mark triangles by rotating the tip while marking. The first mark is made with the tip held at a 45-degree angle to the left, then the marker is rotated 45 degrees to the right to make the corresponding angle. This is repeated 5 mm behind the hairline across the scalp ( Fig. e4.1 ). Although triangles are drawn, the incision is not angular and the peaks of the triangles are rounded with the scalpel. The triangles are only used as a general guide.

A felt-tipped pen is used to mark triangles 5 mm behind the hairline across the proposed incision site by rotating the tip right and left to make equal angles. The angles will be rounded in the final incision.

Transfollicular Incision and Healing

The reason this incision heals so well when performed properly is that the transected hair follicles can regrow through the incision and camouflage the scar. In order for this to occur, the bevel of the incision must transect the hair shafts and follicles at various angles. The most anterior and usually fine vellus hairs may be totally excised and be lost. Generally, this small amount of hair loss is negligible and not noticeable in the final result. The next rows of follicles are transected close to the hair bulb and these are the hairs that will regrow through the scar. The posterior-most hair shafts will be transected towards the top of the shaft and these will also grow back ( Fig. 4.30 ).

The extreme bevel of the incision will cut the anterior hairline follicles low and the successive posterior rows of hair higher on the shaft. It is the more anterior hairs that will regrow through the incision to camouflage the scar.

Although some hair may be excised when trimming the flap, it should be negligible if the incision is made correctly ( Fig. 4.31 ). It may appear that more hair is lost when incising, but it is important to remember that some of the rows of follicles that appear to be cut will actually regrow through the scar; in effect these hairs are cut but not lost.

Although it appears that some hair is excised when trimming the forehead flap, many of the hairs are cut above the hair bulb and will regrow through the scar.

As with any surgical procedure, a learning curve is associated with this technique but when mastered, the postoperative scar and hairline can be virtually undetectable ( Fig. 4.32 ).

The excellent hairline aesthetics that can be achieved with the described transfollicular approach.

The reason that the incision cannot be made more posteriorly than 5 mm is that if the incision is made more posteriorly, more hair will be removed during flap trimming and the hairline will be elevated, which is counterintuitive to this hair-sparing technique. The further back the incision is made on the scalp, the more the procedure resembles a coronal lift and elevates the hairline. In some patients, the incision may be slightly posterior, such as 7 mm, but beyond that, excessive anterior hair will be lost during skin excision. When the incision is close to the hairline, the excised tissue will be forehead skin and not hair. The incision does need to be posterior enough to accept a long bevel with the No.11 scalpel blade and 5–6 mm is generally adequate. Patients with thick straight hairlines across the entire forehead are the easiest candidates for novice surgeons. For patients that have do not have a distinct, straight hairline, or have lateral hair recession, the incision must be modified to accommodate the follicular density as it curves around the hairline ( Fig. 4.33 ).

(A) A straight hairline with a simple incision across the forehead. (B) A patient with a temporal recession; these cases require modification of the incision to stay in the denser hairline and follow the curvature.

After the initial hyper-beveled incision is made and dissection completed, the excess forehead skin will be retracted towards the scalp and also trimmed with the same angle bevel as the initial incision. The feather-edged forehead skin flap will then lie on the feather-edged scalp flap to create a very thin epidermal/dermal interface ( Fig. 4.34 ). It is this thin skin interface, which lies over the transected hair shafts and follicles, that allows the hair to regrow through the skin and camouflage the scar ( Fig. 4.35 ). When these incisions are properly performed, new hair regrowth can be seen in the first several weeks after the procedure ( Fig. 4.36 ).

(A) The hyper-beveled forehead skin flap that will overlie the hyper-beveled scalp flap. (B) This thin interface, which overlies transected hair follicles and shafts, will be penetrated by hair regrowth.

Hair regrowth through the thin skin flaps, which camouflages the incision scar.

New hair regrowth through the incision is seen in this patient 4 weeks postoperatively.

Simultaneous Blepharoplasty

I believe that almost any patient that needs a browlift also needs blepharoplasty. I perform simultaneous blepharoplasty with almost all browlifts (endoscopic and transfollicular). The only exceptions are patients that do not have dermatochalasis, or patients that have had previous aggressive upper-lid skin resection. To determine this, I manually elevate the brow to the desired position. If there is redundant lid skin (which there generally is), then I will perform simultaneous blepharoplasty. Another means of estimating the need for blepharoplasty is to lie the patient back in the chair. This automatically places the brows in an elevated position. If there is still excess upper-lid skin in this position, a blepharoplasty is warranted.

After the surgical prep is completed, the incision marking is visualized and several rows of hair are combed forward to expose the scalp where the incision will be made ( Fig. 4.37 ).

Combing several rows of hair forward helps expose the incision marking, thus facilitating the incision.

Anesthesia

As stated earlier, this procedure can be performed with tumescent anesthesia only but is more commonly done with sedation. For tumescent technique, the entire brow and forehead is injected with typical Klein’s solution (0.1% lidocaine with 1 : 1 million epinephrine) with a 23-gauge spinal needle. The tumescent solution is injected from the hairline to the superior orbital rims and laterally to the temporal crests. It is critical that the local anesthesia is injected in the subcutaneous plane, as this is where the dissection will occur. The tumescent solution also produces hydrodissection between the dermis and frontalis, which aids in the actual surgical dissection. The actual hairline where the scalpel incision occurs is injected with 2% lidocaine 1 : 100,000 epinephrine. If the surgeon does not want to use tumescent anesthesia, the entire brow can be injected with the standard 2% lidocaine with epinephrine. Again it is important to infiltrate from just above the planned incision to the superior orbital rims and the entire forehead between the temporal crests ( Fig. 4.38 ). Unlike liposuction, excessive volume of tumescent is unnecessary and only enough fluid to provide anesthesia and hemostasis is used.

(A,B) A 23-gauge spinal needle is used to tumesce (C) the yellow-shaded area. A syringe or peristaltic pump can be used. Alternatively, simple subcutaneous local anesthesia can be injected with a conventional needle.

Dissection

Just as a precision incision is required for this procedure to be successful, the dissection is equally important. Unlike many browlift procedures, this is a subcutaneous dissection. The proper dissection plane is below the dermis (including some subcutaneous fat) and above the frontalis muscle. This plane is similar to facelift surgery and the proper plane must be followed for success with this procedure.

Some surgeons prefer to pretunnel or predissect the subcutaneous flap with blunt dissectors ( Fig. 4.39 ) as similarly performed in facelift surgery. Although this is not a necessary step, it is very helpful, especially for novice surgeons, to find and stay in the correct surgical plane and avoid trauma to the thin frontalis muscle complex.

Blunt dissectors are excellent for creating a pretunnel in the subcutaneous plane. This produces “Swiss cheese” tunnels that facilitate the remainder of the dissection.

After the pretunneling maneuver, the actual flap dissection is begun. Again, this is a subcutaneous dissection made below the dermis and above the frontalis muscle. The dissection is performed with facelift scissors, and it is imperative to remain in the subcutaneous plane and not damage the frontalis muscle or the sensory nerves that lie over it. The surgeon must remain cognizant that long branches of the supratrochlear and supraorbital nerves course from the superior orbital rim to the scalp ( Fig. 4.40 ).

(A) Branches of the supratrochlear and supraorbital nerve run superiorly from the superior orbital rim towards the scalp. (B) Although not encountered in all dissections, care must be taken to stay above the frontalis muscle to preserve the nerve branches.

Scissors dissection is begun at the incision line as the scissors enter the subcutaneous plane. If the flap has been pretunneled, this dissection is easy and can be accomplished by “nipping,” pushing, and spreading with the scissors ( Fig. 4.41 ). This initial scissor dissection can be performed “blindly” (indirect vision) to a point several centimeters above the orbital rim to prevent damage to the supratrochlear and supraorbital nerve branches. Distal to this, all dissection must be completed with direct vision, as the neurovascular bundles are easily visualized. A lighted fiber optic retractor greatly facilitates the surgery. In the midline glabellar region, blunt or sharp dissection can be performed to the nasal radix without fear of nerve injury.

(A) Scissors dissection is carefully performed by “nipping,” advancing and spreading the scissors. (B) This can be performed without direct vision to a point several centimeters above the superior orbital rim, but should be performed with direct vision when approaching the orbital rims to prevent nerve damage.

As the flap is developed, bleeding will occur at the incision site. Minor bleeding will subside but given the vascular nature of the scalp, larger areas of bleeding must be cauterized. Very fine tip bipolar forceps are used and extreme care is exercised not to damage exposed hair follicles ( Fig. 4.42 ). The surgeon must always keep in mind that it is the hair follicles and cut hair shaft that regrow through the scar and any damage to these structures can compromise the result.

Fine-tipped bipolar forceps are used to control bleeding with low power and extreme care is needed not to damage hair follicles that could compromise the result.

After the initial flap is developed, it is completed to the required extent. This can be variable depending on the age of the patient and amount of brow and lid ptosis. In most cases, the lateral extent of the dissection extends just past the brow tail to the point needed to fully elevate the brow ( Fig. 4.43 ). In older patients, or those with extreme ptosis or hooding, the dissection can proceed more laterally, just up to the temporal crest (conjoined tendon) but never exceeds this region laterally ( Fig. 4.44 ). Again, the advantage of this procedure is simplicity. Staying medial to the temporal crest region also prevents damage to the frontal nerve.

(A) The yellow shading shows the usual region of subcutaneous undermining for younger patients or those without significant brow hooding. The blue shading represents regions of lateral extension that can be expanded for older patients or patients with increased brow hooding. (B) The lateral extent of the average case.

In older patients with significant lateral hooding, the incision may be carried more laterally past the brow tail. The white circle shows the lateral extension. This allows any necessary lateral dissection. Dissection is never carried past the temporal crest in this technique.

It is imperative to remember that this is lipocutaneous flap performed in a plane above the frontalis muscle. The flap should have adequate fat on the dermal surface ( Fig. 4.45 ). The frontalis muscle is very thin in some females and sometimes translucent. Gentle dissection in the subdermal, premuscular plane above the muscle is essential to preventing injury.

The basis of the transfollicular subcutaneous browlift technique is to develop a lipocutaneous flap.

Once enough inferior dissection has been performed to accommodate retractors, the remainder of the procedure is performed with direct vision ( Fig. 4.46 ). As the direct vision dissection approaches the superior orbital rims, the anterior flap can be folded inferiorly to facilitate vision. This may not be possible with a small flap on a younger patient, but may be performed with a larger lateral dissection on a patient with increased aging and ptosis ( Fig. 4.47 ).

As the dissection and flap development proceed, direct vision is used. This is a great advantage of this approach. A fiber optic retractor greatly facilitates vision.

As the flap is developed, it can be folded anteriorly for improved vision and access. This may not be possible with smaller flaps that do not extend past the brow tail.

As the dissection continues, the neurovascular bundles of the supratrochlear and supraorbital nerves will be encountered. The advantage of a direct vision approach is the excellent visualization of these structures ( Fig. 4.48 ). As the dissection nears the orbital rims, and hence the neurovascular bundles, judicious and precise surgery is required to prevent nerve injury. In the area of the neurovascular bundles, direct vision should always be used. Blunt facelift scissors are used to gently spread the perineural tissues without disrupting the nerves and vessels. The initial approach is with the scissors used horizontally. The bundles can actually be dissected further by turning the scissors vertically and gently stretching between the bundles for additional release and dissection ( Fig. 4.49 ). The neurovascular bundles can be gently stretched without permanent damage, while dissecting in the subcutaneous plane ( Fig. 4.50 ). This is preferable to having them tethered to the flap, which will later be stretched.

One of the main advantages of the open, direct vision procedure is the excellent visualization of neurovascular structures.

The neurovascular bundles are approached with the scissors in the horizontal plane and the scissors are then rotated 90 degrees to the vertical plane to dissect between the bundles.

(A,B) The same scissors repositioning is shown clinically. The vertical position allows nerve preservation while freeing the tissues.

For surgeons used to endoscopic or coronal approaches, the nerve bundle in these approaches are subperiosteal and the nerve exits a foramen or notch as a distinct single bundle ( Fig. 4.51 ). Damaging this main branch can cause considerable damage. In the subcutaneous approach, the nerve has branched from the bundle, so main trunk damage is less risky.

(A) The supraorbital nerve when viewed from the endoscopic approach exits the foramen as a single bundle. (B) In the subcutaneous approach, the nerve is branched.

As the inferior dissection proceeds, nerves are gently freed from the surrounding tissues or avoided altogether if it is not an obstacle or not interfering with the lift. It is imperative to release the eyebrows completely for effectiveness and stability of the lift, so the surgeon must dissect inferior to the brows and into the upper lids ( Fig. 4.52 ). Since the patient is in the supine position, the brow will almost self-elevate when the appropriate adhesions and tethers are released with the scissors. When the brow is passively released and elevated to the proper arch, the dissection is sufficient. This will differ from patient to patient. Younger patients may only need dissection and elevation to the area of maximum arch but older patients may need dissection to the lateral orbital rim ( Fig. 4.53 ).

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